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New advances can boost the physician-patient relationship, rather than create barriers.
During his residency, John Moore, MD, PhD, saw a persistent problem: Many patients diagnosed with blinding eye diseases would stop using the highly effective prescriptive eye drops that could prevent them from losing their sight.
Moore knew that other doctors also had patients struggling to comply with medicine regimens and other prescribed treatments. And he says he wasn’t surprised, considering that patients typically don’t retain most of the information they get when visiting their doctors.
Part of the blame, Moore says, lies with the medical system. It’s designed to offer episodic care to treat acute problems, even though today most of the country’s medical spending now goes toward treating chronic conditions.
So he set out to change that. In 2007, while still a resident, Moore started writing software that enabled him to collaborate with patients on treatment plans they could print out and take home. He went on to become co-founder and CEO of Twine Health, a Cambridge, Massachusetts-based maker of a software-as-a-service platform that aims to help healthcare providers work with patients on a more collaborative and consistent basis.
Twine’s platform is one of a growing number of technologies that enables greater connections between doctors and their patients. These technologies allow clinicians to collect and monitor patient biometrics without the patients having to visit the doctor’s office.
The technologies also analyze that data using algorithms to identify which patients are doing well and which ones aren’t. Furthermore, these technologies allow clinicians to engage with patients based on their individual results by sending out educational information and motivational material as well as supporting text, chats and personal messages alerting patients on what they need to do next.
Proponents say these technologies have shown they can deliver better patient outcomes at lower costs than traditional healthcare processes. But others caution that getting these technologies into doctors’ offices won’t be easy, because multiple obstacles prevent their widespread adoption. So even though early use cases show strong results using these technologies, very few doctors have implemented them in their practices.
“A lot of physicians are quite resistant to this kind of thing. Their days are already full with a lot of hard work,” says Joseph C. Kvedar, MD, vice president of Partners HealthCare Connected Health, a Boston-based organization studying technology-enabled care delivery and connected health programs. “But [these technologies] are an inevitability. We just have to get to the point where both economically and from a care workflow we have the right balance.”
Gregory R. Weidner, MD, medical director for primary care innovation and proactive health at Carolinas HealthCare System and an internist at a Charlotte, North Carolina, medical practice, says he’s seeing positive results using such technologies.
A team of clinicians-medical assistants, RNs, health coaches and others-launched a pilot program at Carolinas using the Twine platform for about 250 patients with uncontrolled hypertension. The team worked with each patient to develop a personalized plan of action; those plans generally include taking prescription medicine, getting more physical activity and changing their diets, Weidner says.
The Twine platform delivers reminders and tips to patients; collects patient data (such as blood pressure readings) that are analyzed and presented to clinicians; and allows patients and clinicians to interact through text messages and other social channels, Weidner explains.
The platform lets clinicians easily see and encourage those sticking with their plans and to track and reach out to those who aren’t. That functionality, Weidner says, “allows us to make care more continuous and collaborative. By leveraging the technology, we can actually be with them and communicate with them and see how they’re tracking against their plans.”
According to Weidner, 82% of the 254 patients in the pilot had their hypertension under control within 90 days without follow-up doctor visits. Moreover, 93% of the patients reported high satisfaction with the program.
In comparison, hypertension control rates range from 30% to 55%, according to published studies, and the Centers for Disease Control and Prevention cites overall rate of 52%. Additionally, under traditional care models, a patient would usually have two to four visits over a six- to 12-month period to manage uncontrolled hypertension.
Despite such results, adoption of collaborative care technologies is low, Kvedar says. “We’re in the land of early adopters for sure,” he says, noting that most adopters so far are clinicians focused in specialized areas of care, such as hypertension, diabetes, chronic pain and mental health.
Some innovative physicians are fitting Type 2 diabetes patients with activity trackers, organizing them in support groups, and starting friendly competitions to boost activity levels, he says. The trackers can transmit data back to the physicians, helping them monitor the patients’ progress.
Kvedar says there are a variety of products on the market, with some coming from vendors and some being developed by healthcare systems. Carolinas, for example, developed MyCarolinas Tracker, a mobile app that allows patients to track and view their health status. It enables patients to compile health information from different locations, and it syncs information from select exercise trackers, blood pressure cuffs, glucometers, scales, heart rate monitors, pulse oximeters and thermometers. In addition, it allows patients to add information manually, such as laboratory data.
Kvedar says the available platforms often include smartphone and tablet apps and web portals. Many products can collect data seamlessly from patients’ health-related devices, like smart blood pressure cuffs and glucometers as well as Wi-Fi-enabled scales and activity trackers such as Fitbit.
Rasu Shrestha, MD, MBA, chief innovation officer at the University of Pittsburgh Medical Center and executive vice president of UPMC Enterprises, says these technologies could restore a lot of the doctor-patient communication that was lost during the past decade as healthcare went digital. The technology, he points out, allows clinicians to be present not just for 20-minute checkups but throughout the patient’s daily life.
In addition, he believes these technologies can deliver the patient empowerment needed for doctors to move away from focusing on treating the sick toward helping patients stay well.
Shrestha cites a couple of examples to illustrate his point. In one case UPMC is using a mobile app from Lantern, a provider of online mental health wellness services, to deliver services such as personalized coaching to patients.
In the second case, patients with congestive heart failure use a Vivify Health app to access individualized instructions after they’re discharged from the hospital. The app also collects and analyzes data, such as blood pressure readings, to provide clinicians insights on how the patients are doing.
“With Vivify, we’re able to engage the patient in a much more meaningful way. Before Vivify we’d discharge a patient with congestive heart failure with instructions and there would be silence in our interaction with the patient unless the patient came back. We wouldn’t know what was going on for a given period of time,” Shrestha says.
Despite such enthusiasm, Shrestha and other users acknowledge there are significant obstacles to widespread adoption of these technologies – particularly for medical practices that rely on a fee-for-service payment model. That’s because engagement technologies are designed to keep patients healthier and to connect patients with their doctors outside the exam room. And at this point, under traditional reimbursement models, doctors don’t get paid for that work.
Richard Ricciardi, PhD, NP, director of the Agency for Healthcare Research and Quality (AHRQ) division of practice improvement and AHRQ’s senior nursing advisor, says few providers are wholeheartedly embracing these technologies “because they’re not integrated with electronic health records, payment models, [and] reimbursements.”
But Kvedar points out that payment models are changing, and as more doctors get paid under models other than fee-for-service, they’ll see that using technologies to remotely monitor and analyze their patients’ health and encourage healthy habits will save time and money by producing better patient outcomes. “That way I’m using my brick-and-mortar resources to take care of the patients who need it the most,” he
Clinician concerns about adding to their already busy workload is another obstacle, say Kvedar and others. They’ll need to figure out how to incorporate these platforms into their workflows to create efficiencies rather than redundancies.
Kvedar says he’s confident that will happen. He compares these technologies to email; many clinicians once viewed email as burdensome extra work, but now it has nearly replaced voicemail and added efficiencies to boot
Doctors likely will find that connected care technologies fit best into practices where the workflow process includes physician extenders-coaches, patient advocates, nutritionists and other support staff-who can take the lead in using the technologies to teach, motivate and interact with patients as well as track patient data, allowing doctors to focus their time on delivering the highly-skilled care they’ve been trained to provide.
“If it’s just the doctor that’s trying to manage this continuous care delivery, then that’s a lot and it’s not leveraging their skills,” says Moore. “There’s a lot of evidence that the most cost-effective model of care would be a combination of these practice extenders so each one can [work] at the top of their practice.”
David C. Rhew, MD, chief medical officer and head of healthcare and fitness for Samsung Electronics America, which offers technologies in this market, says doctors will have to adjust their mindset. “Physicians have been traditionally focused on what happened in their office,” he says, with doctors assuming that patients follow their instructions once they were sent home. But as any doctor knows, “that doesn’t always occur.”
That could explain why studies show that physicians who follow up after office visits produce better patient outcomes than those who don’t, Rhew says. In the past, such follow-up was time-consuming and costly. But these connected care technologies are designed to make follow-ups easier and enable more collaborations and communication with patients in timely cost-effective ways.
“The more contact you have, the more ability to course correct or reinforce one’s behavior to help them better understand risks, the more you allow patients to become empowered, the better results you’ll get,” he says.
Ricciardi, though, cautions against expecting too much from these technologies. He says they may indeed help patients stay motivated and encourage them to adopt or keep healthy habits, but the patients still must be willing to do whatever work their doctors prescribe, whether it’s adherence to their medication schedule or a nutrition plan.
“I see them as a lever for management, but not a panacea,” says Ricciardi, who in his practice at a Department of Defense facility uses activity trackers as a way to help patients stay motivated and record their physical exercise.
“If you want to help facilitate someone to lose weight and get some physiological data on their activity levels, yes, you could use apps that could track that information and provide a feedback loop,” he says. But in my opinion they’re primarily there to help the patient with self-management.”
Ricciardi adds: “Is this the first thing they think of in terms of self-management? No. Is it part of the tool kit? Yes.”